7A GRISWOLD DR - BUILDING INSPECTION (2) 00
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR,7`h edition R OF S ✓ EM
s nuary
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008
i 0 One-or Two-Family Dwelling
I This Section For Official Use Only
Building Permit No er Date Applied:
6 Signature:
Bw mg omm n � Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Pro erty Address: a �✓ 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Qwneyl of Recor t
r L-NrureU c //7 G ro
Name ' t Address for Service:
' 77d'- 7610 - 3/ 72
S alure ITelephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied jg{ Repairs(s)0 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Propo ed Work': /Zp/J/� �- i�r(+t uui'f U i o�7 E LAJ
1P/Q�Ccce /rw� uitYs
Z'
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 3000, 0O 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $
❑Total Project Cost (Item 6)x multiplier x -
3. Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 3000' 06 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
b(, ,� 66--A -10
41 h.-rvw j L LCw r C Y License Number Expiration Date
Name of CSL-Holder\ ' � List CSL Type(see below)
S�'l aV�1 fiu� V'J�'{
Address 0 Type Description
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted I&2 Family Dw Dwellin
Signature M Mason Only
01 Q �1 (—lUU RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Fgisterecl Home Improvement Contractor(HIC)
Atn ykw ,sld.•c < QCer ,Pet-. S c , �� 3 C'1V
HIC Company Name or HIC Registran Jc� Registration Number
7.U. �uv l7 '�- C- ]4t cr t ✓vr✓.I C�t'i no
Addre �—� — I J
` .b QZ 1( i 0U0 Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No—........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, rel� Z— lQ.f1r/ as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to w thorized by thi uilding permit application.
3
S nature of Owner Date
SECTION 7b:OWNERS OR AUTHORIZED AGENT DECLARATION
I, —L�10�a S L Le< v S -L ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
e- L e w U
Print Nam
Signature of Owner or Authorized Agent Date
'(Signed under the pains and penalties of a u )
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(Sq.Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF S.U.&M, jtLkss xait;SET m
BI MI)LNG DEPARTNIJUNT
I'_0 W.tismiNGTON STRErr. Yo FLOOR
TEL (978) 745.9595
F.%x(978) 744984
KIN®EALEY DIUSCO[L
HAYOII TkOhW ST.PI2?RRs
DIRECCO R OP IK:BLIC PROPERTY/11L'O.DDIG CONMOSSION ER
Workers' Cornpensatlon Insurance Aflldavit: guilders/ContractoNElectriclanslPlumben
annllcant Information n Please Print Legibly
Name(8uairr 0rgaly,raiat►ltdav,dusl): V cxW S�c- Ve �l J\1C-'R�—\ \�.et^'�c G��--, 17� .
Address: h l5 a x
City/State/Zip: SC Vc - - M ham\ Phone N: Cl
,ire you to empieyer'Check the appropriate boa: Type o/project(rtrqulred):
1.q 1 am a crnploya with 4. ❑ 1 an a general contractor and 1sub-contractorsb. ❑New construction
employees(full and/or part-time).• have hired the sub-contractors2.❑ lam a sole propriety ar partner- listed on the attached sheet: 7. ❑Remodeling
:hip and have no employees; se The sub-contraemrs have a. ❑Demolition
working for me in any capacity, workers'comp.irlaursoea A ❑guikling addition
I No workers'comp insurance S. ❑ We are a corporation and id
mguiredl.l offleers have esaeised their 10.❑Electrical repairs y addiriom
).❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.(No workers'comp. c. 132.f 10),and we have no 12.❑Roof repairs
insurance required.)t ctnplayee.(No workers, 1 J.❑Other
comp insurance required.)
.Any applicant that chada ball A ntwl air fill aw the ruim bolow rbawiq thrir warlo a'wmpmari,n policy infimmaden.
'l I.erurn.a who tuhnN this aMdavir indicating they am doing all nark ad"him ou oii amttecrsn nhaar suhnk■,rw at1l,Yea indiceliq nheR
:C.mtromten that)link this tap ntwt anidltaa wl 3,161Ynr AM drying des na,M el lhs wn64vwedm aid their waMe•camp.policy isfaellrtim
l any on eotpikyer that bOrevidling workers'compeatind"/aserswsYJer my ea►plttyeex Qa/ew Is Ik*pNfey owd J4 site
irrfoneatloa
Insurance Company Name: \ \M V\-kJ tlJ 0,
Policy M or Self-ins. Lie.p: Expiralion Date: 31I — I O
Jab Sire Address: _l A l7r�St r_V &2r City/SlatdZip: sG\e" W�
compensation a copy of the workers'compeation policy declaration pop(showing the policy number and atplrsdoo date).
Failure to secure coversp a required under Section 25A of MDL a 152 can lad to the imposition of criminal penalties of e
fine up to S 1.500.00 and/or one-year imprisonment,as well as civil penalties is the form of a STOP WORK ORDER and a Rae
of up to S250.00 a day against the violator. Ile advi.+al that a curly of this statement maybe rurwurded to the Office of
Invesitgmiuns of the DIA for insurance coverage vcriticl n.
/de hereby certify under a paiwa uw pene/i/ el"Pepley that the hifernradow provided above is true and correct
Nwiun re:
Phone-4: 01 7 _ `'l 1 \� L)
Official use un/n no oat write its this area,to be cump/ttd by city or lowly offJc•ial
I
City or ruwn:
i
Asuintl Aulhurily (circle tiney
I. Iltaard of Ileallk 2. Huilding Deparmcnt ).City/ro»n Clerk 4. Electrical Intpccior S. Plumbing Impactor
6.other
I.entad Pcrton: _ . ._ _.. Phone)/:
'S CITY OF SALEM
PUBLIC PROPRERTY
�•� DEPARTMENT
fdl: "W "IN 011
\I .wx Ile vt' u5rxt[i �5.�n�t, �IaS:��In a
I'rl:471t.7450i9S I'%X:47gJ404946
Construction Debris Disposal Affidavit
(required Our all demolition and renovation work)
in accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit N is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
t 11.S 150A.
The debris will be transported by:
ate T �� 1��
(name of hauler)
The debris will be disposed of in
(narm Ulf af;71 y
taddrns�ul'1'aclluy/ i
Signature M I><rmit applicant
due